Microsoft Word - Cataract+Surgery+Direct+Referral+Form[1 ...
Optometrist direct referral for cataract surgery plus choice
Patient NHS Number:
| |Patient |GP |Optometrist |
|Name | | | |
|DOB | | | |
|Address | | | |
| | | | |
| | | | |
| | | | |
|Postcode | | | |
|Telephone | | | |
|email | | |GOC No: 01- |
Surgery required on: - Tick appropriate boxes - First eye Second eye Right eye Left eye
|Refractive Status |Right eye |Left eye |
|Unaided vision | | |
|Best corrected VA |Monocular: PH: |Monocular: PH: |Binoc: |
|Refraction | /- | /- |
|Historical BCVA; Date: / / | | |
Ophthalmic history: Tick where appropriate
|Previous Cataract surgery; Date / / |R |L |Refractive surgery (Px to bring pre & post details to clinic) |R |L |
|Squint / Previous squint surgery |R |L |Amblyopia |R |L |
|Retinal detachment |R |L |Glaucoma |R |L |
|Trauma |R |L |Keratitis |R |L |
|AMD |R |L |Iritis |R |L |
|Other eye surgery or comments: |
| |
General Medical Risk Factors: Tick where appropriate
|Hypertension (must be controlled for surgery) | |Parkinsons | |
|Diabetes (must be controlled for surgery) | |Tamsulosin/Doxazosin | |
|Anticoagulant | |Heart Disease / Heart Surgery | |
|Breathing Problems | |Stroke | |
|Medications (including any eye drops): |Allergies: |
| | |
Ocular Examination: Tick where appropriate
|Aperture: |
General Factors: Tick as appropriate
|Difficulty lying flat & still for surgery | |Slit lamp exam difficult | |
|Previous Reaction on local anaesthetic | |Wheelchair user or poor mobility | |
|Nervous / Anxious / Claustrophobia | |Poor understanding of English | |
Criteria for 1st and 2nd eye cataract surgery
Ipswich and East Suffolk CCG and West Suffolk CCG will only fund cataract surgery when the following criteria are met:
The patient should have sufficient cataract to account for the following visual symptoms as evidenced in the Cataract Referral Form:
• Blurred or dim vision with a corrected binocular distance acuity of 6/10* (0.20 logMAR) or worse OR
• Blurred or dim vision with a corrected monocular distance acuity of 6/18 (0.40 logMAR) or worse OR
• Anisometropia - refractive difference between the two eyes (≥3) resulting in poor binocular
vision or disabling diplopia which may increase the risk of falls
AND
• The cataract should affect the patient’s lifestyle scoring ≥3 as evidenced in the Cataract
Assessment Form (below)
AND
• The patient has waited 7 days to make a decision and wishes to undergo cataract surgery
and understands the risks and benefits of this surgery.
*6/10 equates to 6/9-2 on Snellen chart
Patients need to evidence how cataract is affecting daily activity. A patient needs to score ≥3
|1. Visual disability |Please Tick |Score |
|Affected by glare | |2 |
|Difficulty with reading | |1 |
|Difficulty watching television | |1 |
|Difficulty performing work or hobbies | |1 |
|2. Social functioning (Tick ONE box only) | | |
|Lives alone | |2 |
|Cares for partner | |2 |
|Lives in sheltered accommodation | |1 |
|Lives with carer | |1 |
|Lives in a residential or nursing home | |1 |
|3. Other | | |
|Drives a car/is in paid employment | |1 |
|Mild/moderate hearing impairment | |1 |
|Severe hearing impairment (Deaf) | |2 |
|Has fallen twice or more in the last 12 months | |2 |
|Total Score | | |
Choice of provider service:
Leaflets given to patient: Cataracts and Cataract Surgery – A guide to your choice of hospital
Patient preferred hospital:
Patient – I have had the benefits and risks of cataract surgery explained to me, and want NHS surgery at this time, at the above hospital:
Yes No
I agree/do not agree that any Ophthalmologist to whom I am referred may make information relevant to my eye condition and its treatment available to my Optometrist/OMP. I understand that the final decision on whether or how surgery is approached rests with the surgeon.
Date………………………
Patient’s signature………………………………………………...………………………………….
Print Name …………………………………………………………………………………………………………….
Optometrist’s signature……………………………………………………...……… Date………………………….
Print Name………………………………..……………………………………………….
Instruction to optometrist: Fax this completed form to Evolutio on 0333 240 7729 & send a copy to GP
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